Indications for Subdural Grids versus SEEG versus Depth...

Indications for Subdural Grids versus SEEG versus Depth Electrodes

December, 2012

Jorge Gonzalez-Martinez MD PhD

Epilepsy Center

Cleveland Clinic

American Epilepsy Society | Annual Meeting

Disclosure

None

American Epilepsy Society | Annual Meeting 2012

Learning Objectives

• Discuss specific indications for subdural grids/strips and SEEG in the diagnosis and treatment of refractory focal epilepsy

American Epilepsy Society | Annual Meeting 2012

Differences among depth electrodes, subdural grids with depths and SEEG

Subdural Method Advantages • “Standard procedure” in North

America.

• Optimal coverage of the subdural space adjacent cortex .

• Anatomical relation between cortex and electrode is easily understood.

• Adequate functional mapping capabilities.

• Open procedure, better management of possible intra-operative complications.

• Resection planning is simple to understand.

• Mapping and resections are performed during the same hospital admission.

Pre op MRI Intra-op aspect

Post op Grid-MRI Co-Registration

Hand Motor

Hand Sensory

Face motor

Face sensory

Ictal onset

CORTICAL STIMULATION

Subdural Method Disadvantages

• Poor coverage of deep located cortex.

• Precise anatomical placement in basal and mesial cortex is unpredictable.

• Invasive method (complications can reach 10-15% in some series).

• Poor 3D view.

• Bilateral implantations are more challenging.

Frontal-Temporal-Parietal SBG Implantation

Occipital-Parietal SEEG Implantation

Post-Op MRI after SEEG-Guided Resection

SEEG after Subdurals

Follow-up: 20 months SF: 6/10

Gonzalez-Martinez et al., submitted

SEEG Method Advantages • Precise and accurate

mapping of deep cortical areas.

• 3D aspect of the hypothetical EZ.

• “less invasive”. 3-5% complication rate.

• Electrode implantation is predictable.

• Intra-cortical recordings.

• Bilateral implantations are straightforward.

Gonzalez-Martinez et al., 2012; Cossu et al., 2005; Talairach et al., 1972

30 y.o. Visual aura and dialeptic seizures

The 3D Mapping the EZ network

SEEG Disadvantages

• Contiguous superficial coverage is poor. • Superficial functional mapping is challenging,

requiring speculation of the anatomical limits of a specific functional area.

• Imprecise interface between the hypothetical EZ and functional areas (mainly speech).

• Anatomical-electrophysiological correlation and the 3D aspect of the EZ are difficult to understand.

• “Blind” procedure. Poor control of IC bleedings.

S

N

W

H

M

R

Z

2 3 1

3 6 7

1 2

3 4

Face

Language

Upper extremity

Motor Lower extremity

54

54

54

Face

Upper extremity

Sensory Lower extremity

65

65

65

54 Eye field

65

65 Negative Motor

65 Stimulated

5 4

1 2 5 6 7

Language Mapping

Clinical scenario Method of Choice

Second Option

• Lesional MRI: Lesion is superficially located, near or in eloquent cortex.

• Normal MRI: Hypothetical EZ located in the proximity of eloquent cortex (mainly speech).

SBG SEEG

• Lesional MRI: Lesion is deep located.

• Normal MRI: hypothetical EZ is deeply located or located in non-eloquent areas.

SEEG SBG with depths

• Need for Bilateral explorations/reoperations

SEEG SBG with depths

• After SBG failure SEEG SBG with depths

• Need for epileptogenic network mapping.

SEEG SBD with depths

Impact on Clinical Care and Practice